Provider Demographics
NPI:1336634377
Name:GUSTAFSON, MARY ELIZABETH (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:ELIZABETH
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13718 340TH ST
Mailing Address - Street 2:
Mailing Address - City:CENTER CITY
Mailing Address - State:MN
Mailing Address - Zip Code:55012-9652
Mailing Address - Country:US
Mailing Address - Phone:651-470-8318
Mailing Address - Fax:
Practice Address - Street 1:2600 65TH AVE
Practice Address - Street 2:
Practice Address - City:OSCEOLA
Practice Address - State:WI
Practice Address - Zip Code:54020-4370
Practice Address - Country:US
Practice Address - Phone:715-294-4050
Practice Address - Fax:715-294-5690
Is Sole Proprietor?:No
Enumeration Date:2018-06-22
Last Update Date:2018-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN115719183500000X, 1835P0018X
WI15851-40183500000X, 1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist